ACR SOTA Symposium: Precision Medicine in Rheumatology

At the American College of Rheumatology's (ACR) 2018 State-of-the-Art (SOTA) Symposium, held last week in Chicago, Illinois, Judith James, MD, PhD, chair of arthritis and clinical immunology at Oklahoma Medical Research Foundation, presented a talk on precision medicine in rheumatology.

James opened her talk by highlighting the differences between precision medicine and personalized medicine. James explained, “Precision medicine is understanding a disease at a deeper level in order to develop more targeted therapies, while personalized medicine is when therapeutics are synthesized for a specific individual.”

James went on to discuss a few steps toward precision medicine already that exist in rheumatology, such as the following:

• Individual monitoring and dose escalation in patients with gout
• Treat-to-target strategies in rheumatoid arthritis (RA)
• Antibody testing for patient stratification in RA, systemic sclerosis, myositis, and other diseases

“Historically, rheumatologists have the highest number of FDA-approved biomarkers for tests in rheumatology compared to all other medicine specialties,” said James.

Although some forms of precision medicine exist in rheumatology already, there is still a long way to go. “We need better information to help us select the right drug, at the right dose, at the right time, in the right patient, and that will hopefully optimize outcomes.”

In addition, James explained how to optimize biologic drugs’ efficacy in RA, citing different factors and their respective effects on treatment, such as increased body mass index (BMI), smoking, the presence of antibodies, and concurrent methotrexate or other disease-modifying anti-rheumatic drugs (DMARD).

Increased BMI leads to worse outcomes in RA, a problem that can be avoided through diet-induced weight loss of 5% to 10%, which has been found to improve disease activity without needing to increase DMARD dosing. In addition, smoking leads to worse outcomes with increased extra-articular manifestations, as well as adversely affecting anti—tumor necrosis factor therapy. The presence of auto-antibodies is associated with better efficacy of rituximab and abatacept in seropositive disease. Finally, James noted, all biologics perform better when used together with methotrexate.

In closing her talk, James discussed different precision medicine factors currently being investigated for their potential use in rheumatology:

• Personalized therapies, such as regulatory T cells, and chimeric antigen receptor (CAR) T-cell therapy
• Genetic counseling
• Risk profiling for potential prevention of disease

“We’re going to different types of interactions with different kinds of health professionals that we haven’t historically used in rheumatology, like molecular pathologists, genetic counselors, and health coaches,” said James.